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Hospital preparedness for weapons of mass destruction incidents: An initial assessment
BRIEF REPORT
Hospital Preparedness for Weapons of Mass Destruction Incidents: An Initial Assessment
From the Center for Rural Emergency Medicine,* the Department of Emergency Medicine,‡ and the Virtual Medical Campus,§ West Virginia University, Morgantown, WV. Author contributions are provided at the end of this article. Received for publication January 5, 2001. Revision received April 3, 2001. Accepted for publication June 13, 2001. Supported by the Office for State and Local Preparedness Support, the Office of Justice Programs, the US Department of Justice (award No. 2000-LF-CX-0001). Address for reprints: Janet M. Williams, MD, PO Box 9151, Morgantown, WV 26506-9151; 304-293-6682, fax 304-293-0265; E-mail [email protected]. Copyright © 2001 by the American College of Emergency Physicians. 0196-0644/2001/$35.00 + 0 47/1/118009 doi:10.1067/mem.2001.118009
Kimberly N. Treat, MD* Janet M. Williams, MD*‡ Paul M. Furbee, MA* William G. Manley, RN* Floyd K. Russell, EdD§ Clarence D. Stamper, Jr.§
Study objective: We performed an assessment of hospital preparedness for weapons of mass destruction (WMD) incidents in Federal Emergency Management Agency (FEMA) Region III. Methods: Interviews of hospital personnel were completed in 30 hospitals. Data collected included level of preparedness, mass decontamination capabilities, training of hospital staff, and facility security capabilities. Results: No respondents believed their sites were fully prepared to handle a biologic incident, 73% (22/30) believed they were not prepared to manage a chemical weapons incident, and 73% believed they were unprepared to handle a nuclear event. If a WMD incident were to occur, 73% of respondents stated a single-room decontamination process would be set up. Four (13%) hospitals (all rural) reported no decontamination plans. WMD preparedness had been incorporated into hospital disaster plans by 27% (8/30) of facilities. Eighty-seven percent (26/30) believed their emergency department could manage 10 to 50 casualties at once. Only 1 facility had stockpiled any medications for WMD treatment. All facilities had established networks of communication. No hospital had preprepared media statements specific to WMD. Nearly one fourth (7/30) stated that their hospital staff had some training in WMD event management. All reported need for WMD-specific training but identified obstacles to achieving this. Seventy-seven percent (23/30) of hospitals had a facility security plan in place, and half were able to perform a hospital-wide lock down. Ninety-six percent (29/30) reported no awareness regarding the threat of a secondary device. Conclusion: Hospitals in this sample do not appear to be prepared to handle WMD events, especially in areas such as mass decontamination, mass medical response, awareness among health care professionals, health communications, and facility security. Further research is warranted, including a detailed assessment of WMD preparedness using a statistically valid
5 6 2
ANNALS OF EMERGENCY MEDICINE
38:5 NOVEMBER 2001
PREPAREDNESS FOR WEAPONS OF MASS DESTRUCTION INCIDENTS Treat et al
sample representative of hospital emergency personnel at the national level. [Treat KN, Williams JM, Furbee PM, Manley WG, Russell FK, Stamper CD Jr. Hospital preparedness for weapons of mass destruction incidents: an initial assessment. Ann Emerg Med. November 2001;38:562-565.] INTRODUCTION
Because of increasing threats of weapons of mass destruction (WMD) terrorism, hospital emergency personnel face the challenge of organizing and implementing a mass medical response to such acts that may require immediate decontamination and treatment of large numbers of casualties, as well as an increased focus on the protection and safety of health care workers.1-3 Furthermore, patients exposed to a biologic agent may not have symptoms for hours, days, or weeks after the attack and may present in geographically dispersed areas. In surreptitious attacks involving agents like smallpox, the first responders are likely to be community and hospital physicians and nurses.4 In an actual WMD event, key hospital personnel (including the CEO, director of nursing, emergency department director, ED nurse manager, and chief hospital engineer or local equivalents) would be called on to focus community medical responses.5 This group, defined as the hospital emergency community of practice (HEMCOP), includes key personnel who would need to command a fairly large body of knowledge to deal effectively with a large-scale WMD event.6 National WMD readiness and preparedness training has focused on the traditional firstresponder communities, such as emergency medical services (EMS), fire, and law enforcement personnel and the military. The current level of civilian hospital preparedness has not been well described. The purpose of this study is to assess the training needs of emergency personnel for WMD preparedness in selected hospitals in Federal Emergency Management Agency (FEMA) Region III. M AT E R I A L S A N D M E T H O D S
A convenience sample of 40 hospitals was generated to assess hospital readiness in FEMA Region III. This region was chosen because the area was familiar to the authors and because the funding sponsor expressed preference for a geographic area compatible with federal interagency disaster planning and coordination. Although both rural and urban facilities were represented, our sample included
NOVEMBER 2001
38:5
ANNALS OF EMERGENCY MEDICINE
10 West Virginia hospitals to examine issues unique to rural areas within our geographic region. This methodology was not intended to be statistically representative of FEMA Region III but rather to help develop an initial understanding of the extent of information and training needs in our region. Of the 40 hospitals, interviews were completed with 30 hospitals during a 30-day period. Two research staff members who had previous awareness training in WMD performed the interviews. On the basis of availability, either the ED medical director or ED nurse manager at each site was interviewed. The structured interview used an instrument that was developed in collaboration with American College Testing. The institutional review board approved this assessment project at our university. Data collected from each respondent included perceived level of hospital preparedness (not at all, somewhat, or fully prepared), mass decontamination and medical response capabilities, training of hospital staff, and facility issues. R E S U LT S
Seventeen ED medical directors and 13 ED nurse managers were interviewed. Participating hospitals were widely dispersed in FEMA Region III as follows: West Virginia (n=11), Pennsylvania (n=10), Maryland (n=5), Virginia (n=3), and the District of Columbia (n=1). These included 22 rural and 8 urban hospitals, as defined with the American Hospitals Association classification. None of the respondents believed their sites were fully prepared to handle a biologic incident. Approximately three fourths (22/30) believed that their sites were not prepared at all, and 8/30 (26%, all urban hospitals) believed their sites were somewhat prepared. Regarding chemical weapons, 73% (22/30) believed they were not prepared at all, and 26% (all urban) believed they were somewhat prepared. The reported level of preparedness for nuclear weapons was similar to the biologic and chemical weapons response, with the exception that 1 respondent believed that his or her facility was fully prepared. This facility was located near a nuclear power plant, where local plans and drills for a power plant incident might translate to a nuclear weapons scenario; however, the respondent believed the facility was ill prepared to handle a biologic or chemical weapons attack. Reported levels of preparedness in urban and rural facilities are shown in the Table. Most (22/30) respondents stated that a single-room decontamination process would be set up to handle 1 victim at a time. Thirteen percent (4/30, all urban) reported
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PREPAREDNESS FOR WEAPONS OF MASS DESTRUCTION INCIDENTS Treat et al
having a mobile decontamination station that could process 10 to 15 patients at a time. Four (13%) hospitals (all rural) reported having no decontamination plans in place. WMD preparedness had been incorporated into hospital disaster plans at 27% (8/30) of the facilities. Eightyseven percent (26/30) of the respondents believed their ED could manage 10 to 50 disaster casualties at a time. Only 10% (all urban) perceived the ability to manage 50 to 100 casualties. One respondent, from a facility in a major metropolitan area, believed that facility could manage more than 500 casualties at a time. With the exception of 1 facility, all respondents reported having plans in place for patient overflow to other medical facilities to accommodate seasonal fluctuations in patient census. However, none of the facilities reported having specific agreements delineated for managing mass casualties in disaster situations. With the exception of tetanus, no vaccines were reported as being stockpiled by any facility. One respondent reported that their pharmacy stockpiled ciprofloxacin for possible anthrax exposure, and no other respondents reported the practice of antibiotic drug stockpiling specifically for WMD events. All facilities reported having established networks of communications, with private telephone lines and radios for use during disaster management. All sites reported having call-out systems using either a telephone call list (25/30) or a paging system (5/30). No sites reported concern for lack of secure or encrypted communication systems.
Table.
Level of preparedness by type of facility. Type of Facility Level of Preparation Chemical Fully Partial None Biologic Fully Partial None Nuclear Fully Partial None
5 6 4
Urban
Rural
Total
1 7 0
0 0 22
1 7 22
0 8 0
0 0 22
0 8 22
1 7 0
0 0 22
1 7 22
Nearly all (28/30) respondents reported having public relations staff to handle media inquiries and to serve as community liaisons with families during disaster events. None of the hospitals surveyed reported having preprepared media statements or communications plans specifically for use during a WMD incident. Nearly one fourth (7/30) of respondents stated that hospital staff at their facility had received some lecturebased or continuing medical education courses on WMD. One metropolitan hospital had conducted mandated training for all clinical personnel. All respondents reported a need for WMD training but identified obstacles to achieving adequate training: (1) lack of time available for training; (2) lack of available courses; and (3) lack of funding required to train large numbers of personnel. Survey respondents were asked what training format they would prefer and would be most accessible. Seventythree percent (22/30) of respondents stated they preferred on-site teaching, including scenarios and practice drills. Others stated a preference for Internet courses with virtual reality simulation. However, several rural hospital respondents reported limited access to the Internet and computers. The combination of pre-event training and just-in-time learning was preferred in 43% (13/30) of the hospital respondents surveyed. One fifth (6/30) of the hospital respondents (all urban) stated that disaster drills specifically for WMD events were conducted. Of these, 1 addressed biologic weapons, 3 addressed chemical weapons, and 3 addressed nuclear weapons. The drills included other hospitals; EMS, fire, and police personnel; and (in 1 case) the Public Health Service. Seventy-seven percent (23/30) of hospitals reported having a security plan in place, and one half stated that they were able to perform a hospital-wide lock down without outside assistance. When asked about the possibility of a secondary device set by a terrorist to injure or kill health care workers who are trying to care for sick or injured patients, 96% (29/30) reported not being aware of or prepared to deal with a secondary device. DISCUSSION
Among hospital emergency personnel, there appear to be significant gaps in knowledge and skill-content areas, including mass decontamination, mass medical response, WMD awareness among health care professionals, health communications, and facility security. One recent study of English hospitals also found both decontamination facilities and personal protective equipment for health
ANNALS OF EMERGENCY MEDICINE
38:5 NOVEMBER 2001
PREPAREDNESS FOR WEAPONS OF MASS DESTRUCTION INCIDENTS Treat et al
care providers to be lacking.7 At greater risk may be the rural facilities that rely on local EMS personnel to perform decontamination. This is of concern because up to 80% of disaster victims may seek hospital care without accessing EMS.8 Greater coordination with federal agencies will be required for timely access to vaccine and medicine stockpiles.9 No facility reported having lines of communication free of potential security issues and system failures.10 Because of the sampling methodology used, our results cannot be generalized to all hospitals in FEMA Region III or nationwide. Furthermore, the lack of awareness and preparedness exhibited by our data may, in part, be a result of the fact that only clinical personnel from the HEMCOP were interviewed. Further research is warranted, including a detailed assessment of WMD preparedness using a statistically valid sample representative of the HEMCOP at the national level. Author contributions: JMW, FKR, and CDS obtained research funding and conceived the study. KNT, JMW, PMF, and WGM designed the study methodology. KNT and WGM collected all data. PMF managed data including quality control and provided advice on survey research design. KNT drafted the manuscript. JMW revised the manuscript and all authors contributed substantially to the revision. JMW takes responsibility for the paper as a whole. We thank the staff of the Office for State and Local Preparedness Support, Office of Justice Programs, US Department of Justice, for their helpful review throughout the study on which this article is based. We also thank RickiAnn Saylor, PhD; Chuck Friedman, PhD; and Sally Chai, PhD, for their expertise and assistance in the design and development of the survey instrument used in this study.
REFERENCES 1. Keim M, Kaufman AF. Principles for emergency response to bioterrorism. Ann Emerg Med. 1999;34:177-182. 2. Richards CF, Burstein JL, Waeckerle JF, et al. Emergency physicians and biological terrorism. Ann Emerg Med. 1999;34:183-190. 3. English JF, Cundiff MY, Malone JD, et al. Bioterrorism Readiness Plan: A Template for Healthcare Facilities. Washington, DC: APIC Bioterrorism Task Force, CDC Hospital Infections Program Bioterrorism Working Group; 1999. 4. Eitzen EM Jr. Education is the key to defense against bioterrorism. Ann Emerg Med. 1999;34:221-223. 5. Wenger CW, Snyder WM. Communities of practice: the organizational frontier. Harvard Business Review. 2000;Jan-Feb:139-145. 6. Brennan RJ, Waeckerle JF, Sharp TW, et al. Chemical warfare agents: emergency medical and emergency public health issues. Ann Emerg Med. 1999;34:191-204. 7. Saunders P, Ward G. Decontamination of chemically contaminated casualties: implications for the health service and a regional strategy. Prehosp Immediate Care. 2000;4:122-125. 8. Tetsu O, Suzuki K, Fukuda A, et al. The Tokyo subway sarin attack: disaster management, Part 2: hospital response. Acad Emerg Med. 1998;5:618-624. 9. Department of Health and Human Services. US Public Health Service. Emergency support function No. 8. Health and Medical Services Annex. Available at: http://www.fema.gov/r-nr/frp/frpef8.htm. Accessed on July 8, 1999. 10. Garshnek V, Burkle FM Jr. Telecommunications systems in support of disaster medicine: applications of basic information pathways. Ann Emerg Med. 1999;34:213-218.
NOVEMBER 2001
38:5
ANNALS OF EMERGENCY MEDICINE
5 6 5
Hospital Preparedness for Weapons of Mass Destruction Incidents: An Initial Assessment
From the Center for Rural Emergency Medicine,* the Department of Emergency Medicine,‡ and the Virtual Medical Campus,§ West Virginia University, Morgantown, WV. Author contributions are provided at the end of this article. Received for publication January 5, 2001. Revision received April 3, 2001. Accepted for publication June 13, 2001. Supported by the Office for State and Local Preparedness Support, the Office of Justice Programs, the US Department of Justice (award No. 2000-LF-CX-0001). Address for reprints: Janet M. Williams, MD, PO Box 9151, Morgantown, WV 26506-9151; 304-293-6682, fax 304-293-0265; E-mail [email protected]. Copyright © 2001 by the American College of Emergency Physicians. 0196-0644/2001/$35.00 + 0 47/1/118009 doi:10.1067/mem.2001.118009
Kimberly N. Treat, MD* Janet M. Williams, MD*‡ Paul M. Furbee, MA* William G. Manley, RN* Floyd K. Russell, EdD§ Clarence D. Stamper, Jr.§
Study objective: We performed an assessment of hospital preparedness for weapons of mass destruction (WMD) incidents in Federal Emergency Management Agency (FEMA) Region III. Methods: Interviews of hospital personnel were completed in 30 hospitals. Data collected included level of preparedness, mass decontamination capabilities, training of hospital staff, and facility security capabilities. Results: No respondents believed their sites were fully prepared to handle a biologic incident, 73% (22/30) believed they were not prepared to manage a chemical weapons incident, and 73% believed they were unprepared to handle a nuclear event. If a WMD incident were to occur, 73% of respondents stated a single-room decontamination process would be set up. Four (13%) hospitals (all rural) reported no decontamination plans. WMD preparedness had been incorporated into hospital disaster plans by 27% (8/30) of facilities. Eighty-seven percent (26/30) believed their emergency department could manage 10 to 50 casualties at once. Only 1 facility had stockpiled any medications for WMD treatment. All facilities had established networks of communication. No hospital had preprepared media statements specific to WMD. Nearly one fourth (7/30) stated that their hospital staff had some training in WMD event management. All reported need for WMD-specific training but identified obstacles to achieving this. Seventy-seven percent (23/30) of hospitals had a facility security plan in place, and half were able to perform a hospital-wide lock down. Ninety-six percent (29/30) reported no awareness regarding the threat of a secondary device. Conclusion: Hospitals in this sample do not appear to be prepared to handle WMD events, especially in areas such as mass decontamination, mass medical response, awareness among health care professionals, health communications, and facility security. Further research is warranted, including a detailed assessment of WMD preparedness using a statistically valid
5 6 2
ANNALS OF EMERGENCY MEDICINE
38:5 NOVEMBER 2001
PREPAREDNESS FOR WEAPONS OF MASS DESTRUCTION INCIDENTS Treat et al
sample representative of hospital emergency personnel at the national level. [Treat KN, Williams JM, Furbee PM, Manley WG, Russell FK, Stamper CD Jr. Hospital preparedness for weapons of mass destruction incidents: an initial assessment. Ann Emerg Med. November 2001;38:562-565.] INTRODUCTION
Because of increasing threats of weapons of mass destruction (WMD) terrorism, hospital emergency personnel face the challenge of organizing and implementing a mass medical response to such acts that may require immediate decontamination and treatment of large numbers of casualties, as well as an increased focus on the protection and safety of health care workers.1-3 Furthermore, patients exposed to a biologic agent may not have symptoms for hours, days, or weeks after the attack and may present in geographically dispersed areas. In surreptitious attacks involving agents like smallpox, the first responders are likely to be community and hospital physicians and nurses.4 In an actual WMD event, key hospital personnel (including the CEO, director of nursing, emergency department director, ED nurse manager, and chief hospital engineer or local equivalents) would be called on to focus community medical responses.5 This group, defined as the hospital emergency community of practice (HEMCOP), includes key personnel who would need to command a fairly large body of knowledge to deal effectively with a large-scale WMD event.6 National WMD readiness and preparedness training has focused on the traditional firstresponder communities, such as emergency medical services (EMS), fire, and law enforcement personnel and the military. The current level of civilian hospital preparedness has not been well described. The purpose of this study is to assess the training needs of emergency personnel for WMD preparedness in selected hospitals in Federal Emergency Management Agency (FEMA) Region III. M AT E R I A L S A N D M E T H O D S
A convenience sample of 40 hospitals was generated to assess hospital readiness in FEMA Region III. This region was chosen because the area was familiar to the authors and because the funding sponsor expressed preference for a geographic area compatible with federal interagency disaster planning and coordination. Although both rural and urban facilities were represented, our sample included
NOVEMBER 2001
38:5
ANNALS OF EMERGENCY MEDICINE
10 West Virginia hospitals to examine issues unique to rural areas within our geographic region. This methodology was not intended to be statistically representative of FEMA Region III but rather to help develop an initial understanding of the extent of information and training needs in our region. Of the 40 hospitals, interviews were completed with 30 hospitals during a 30-day period. Two research staff members who had previous awareness training in WMD performed the interviews. On the basis of availability, either the ED medical director or ED nurse manager at each site was interviewed. The structured interview used an instrument that was developed in collaboration with American College Testing. The institutional review board approved this assessment project at our university. Data collected from each respondent included perceived level of hospital preparedness (not at all, somewhat, or fully prepared), mass decontamination and medical response capabilities, training of hospital staff, and facility issues. R E S U LT S
Seventeen ED medical directors and 13 ED nurse managers were interviewed. Participating hospitals were widely dispersed in FEMA Region III as follows: West Virginia (n=11), Pennsylvania (n=10), Maryland (n=5), Virginia (n=3), and the District of Columbia (n=1). These included 22 rural and 8 urban hospitals, as defined with the American Hospitals Association classification. None of the respondents believed their sites were fully prepared to handle a biologic incident. Approximately three fourths (22/30) believed that their sites were not prepared at all, and 8/30 (26%, all urban hospitals) believed their sites were somewhat prepared. Regarding chemical weapons, 73% (22/30) believed they were not prepared at all, and 26% (all urban) believed they were somewhat prepared. The reported level of preparedness for nuclear weapons was similar to the biologic and chemical weapons response, with the exception that 1 respondent believed that his or her facility was fully prepared. This facility was located near a nuclear power plant, where local plans and drills for a power plant incident might translate to a nuclear weapons scenario; however, the respondent believed the facility was ill prepared to handle a biologic or chemical weapons attack. Reported levels of preparedness in urban and rural facilities are shown in the Table. Most (22/30) respondents stated that a single-room decontamination process would be set up to handle 1 victim at a time. Thirteen percent (4/30, all urban) reported
5 6 3
PREPAREDNESS FOR WEAPONS OF MASS DESTRUCTION INCIDENTS Treat et al
having a mobile decontamination station that could process 10 to 15 patients at a time. Four (13%) hospitals (all rural) reported having no decontamination plans in place. WMD preparedness had been incorporated into hospital disaster plans at 27% (8/30) of the facilities. Eightyseven percent (26/30) of the respondents believed their ED could manage 10 to 50 disaster casualties at a time. Only 10% (all urban) perceived the ability to manage 50 to 100 casualties. One respondent, from a facility in a major metropolitan area, believed that facility could manage more than 500 casualties at a time. With the exception of 1 facility, all respondents reported having plans in place for patient overflow to other medical facilities to accommodate seasonal fluctuations in patient census. However, none of the facilities reported having specific agreements delineated for managing mass casualties in disaster situations. With the exception of tetanus, no vaccines were reported as being stockpiled by any facility. One respondent reported that their pharmacy stockpiled ciprofloxacin for possible anthrax exposure, and no other respondents reported the practice of antibiotic drug stockpiling specifically for WMD events. All facilities reported having established networks of communications, with private telephone lines and radios for use during disaster management. All sites reported having call-out systems using either a telephone call list (25/30) or a paging system (5/30). No sites reported concern for lack of secure or encrypted communication systems.
Table.
Level of preparedness by type of facility. Type of Facility Level of Preparation Chemical Fully Partial None Biologic Fully Partial None Nuclear Fully Partial None
5 6 4
Urban
Rural
Total
1 7 0
0 0 22
1 7 22
0 8 0
0 0 22
0 8 22
1 7 0
0 0 22
1 7 22
Nearly all (28/30) respondents reported having public relations staff to handle media inquiries and to serve as community liaisons with families during disaster events. None of the hospitals surveyed reported having preprepared media statements or communications plans specifically for use during a WMD incident. Nearly one fourth (7/30) of respondents stated that hospital staff at their facility had received some lecturebased or continuing medical education courses on WMD. One metropolitan hospital had conducted mandated training for all clinical personnel. All respondents reported a need for WMD training but identified obstacles to achieving adequate training: (1) lack of time available for training; (2) lack of available courses; and (3) lack of funding required to train large numbers of personnel. Survey respondents were asked what training format they would prefer and would be most accessible. Seventythree percent (22/30) of respondents stated they preferred on-site teaching, including scenarios and practice drills. Others stated a preference for Internet courses with virtual reality simulation. However, several rural hospital respondents reported limited access to the Internet and computers. The combination of pre-event training and just-in-time learning was preferred in 43% (13/30) of the hospital respondents surveyed. One fifth (6/30) of the hospital respondents (all urban) stated that disaster drills specifically for WMD events were conducted. Of these, 1 addressed biologic weapons, 3 addressed chemical weapons, and 3 addressed nuclear weapons. The drills included other hospitals; EMS, fire, and police personnel; and (in 1 case) the Public Health Service. Seventy-seven percent (23/30) of hospitals reported having a security plan in place, and one half stated that they were able to perform a hospital-wide lock down without outside assistance. When asked about the possibility of a secondary device set by a terrorist to injure or kill health care workers who are trying to care for sick or injured patients, 96% (29/30) reported not being aware of or prepared to deal with a secondary device. DISCUSSION
Among hospital emergency personnel, there appear to be significant gaps in knowledge and skill-content areas, including mass decontamination, mass medical response, WMD awareness among health care professionals, health communications, and facility security. One recent study of English hospitals also found both decontamination facilities and personal protective equipment for health
ANNALS OF EMERGENCY MEDICINE
38:5 NOVEMBER 2001
PREPAREDNESS FOR WEAPONS OF MASS DESTRUCTION INCIDENTS Treat et al
care providers to be lacking.7 At greater risk may be the rural facilities that rely on local EMS personnel to perform decontamination. This is of concern because up to 80% of disaster victims may seek hospital care without accessing EMS.8 Greater coordination with federal agencies will be required for timely access to vaccine and medicine stockpiles.9 No facility reported having lines of communication free of potential security issues and system failures.10 Because of the sampling methodology used, our results cannot be generalized to all hospitals in FEMA Region III or nationwide. Furthermore, the lack of awareness and preparedness exhibited by our data may, in part, be a result of the fact that only clinical personnel from the HEMCOP were interviewed. Further research is warranted, including a detailed assessment of WMD preparedness using a statistically valid sample representative of the HEMCOP at the national level. Author contributions: JMW, FKR, and CDS obtained research funding and conceived the study. KNT, JMW, PMF, and WGM designed the study methodology. KNT and WGM collected all data. PMF managed data including quality control and provided advice on survey research design. KNT drafted the manuscript. JMW revised the manuscript and all authors contributed substantially to the revision. JMW takes responsibility for the paper as a whole. We thank the staff of the Office for State and Local Preparedness Support, Office of Justice Programs, US Department of Justice, for their helpful review throughout the study on which this article is based. We also thank RickiAnn Saylor, PhD; Chuck Friedman, PhD; and Sally Chai, PhD, for their expertise and assistance in the design and development of the survey instrument used in this study.
REFERENCES 1. Keim M, Kaufman AF. Principles for emergency response to bioterrorism. Ann Emerg Med. 1999;34:177-182. 2. Richards CF, Burstein JL, Waeckerle JF, et al. Emergency physicians and biological terrorism. Ann Emerg Med. 1999;34:183-190. 3. English JF, Cundiff MY, Malone JD, et al. Bioterrorism Readiness Plan: A Template for Healthcare Facilities. Washington, DC: APIC Bioterrorism Task Force, CDC Hospital Infections Program Bioterrorism Working Group; 1999. 4. Eitzen EM Jr. Education is the key to defense against bioterrorism. Ann Emerg Med. 1999;34:221-223. 5. Wenger CW, Snyder WM. Communities of practice: the organizational frontier. Harvard Business Review. 2000;Jan-Feb:139-145. 6. Brennan RJ, Waeckerle JF, Sharp TW, et al. Chemical warfare agents: emergency medical and emergency public health issues. Ann Emerg Med. 1999;34:191-204. 7. Saunders P, Ward G. Decontamination of chemically contaminated casualties: implications for the health service and a regional strategy. Prehosp Immediate Care. 2000;4:122-125. 8. Tetsu O, Suzuki K, Fukuda A, et al. The Tokyo subway sarin attack: disaster management, Part 2: hospital response. Acad Emerg Med. 1998;5:618-624. 9. Department of Health and Human Services. US Public Health Service. Emergency support function No. 8. Health and Medical Services Annex. Available at: http://www.fema.gov/r-nr/frp/frpef8.htm. Accessed on July 8, 1999. 10. Garshnek V, Burkle FM Jr. Telecommunications systems in support of disaster medicine: applications of basic information pathways. Ann Emerg Med. 1999;34:213-218.
NOVEMBER 2001
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ANNALS OF EMERGENCY MEDICINE
5 6 5